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Women & Criminal Justice

ISSN: 0897-4454 (Print) 1541-0323 (Online) Journal homepage: https://www.tandfonline.com/loi/wwcj20

Mental Health Among Incarcerated Women: An Examination of Factors Impacting Depression and PTSD Symptomology

Mollimichelle Cabeldue, Ashley Blackburn & Janet L. Mullings

To cite this article: Mollimichelle Cabeldue, Ashley Blackburn & Janet L. Mullings (2019) Mental Health Among Incarcerated Women: An Examination of Factors Impacting Depression and PTSD Symptomology, Women & Criminal Justice, 29:1, 52-72, DOI: 10.1080/08974454.2018.1433099

To link to this article: https://doi.org/10.1080/08974454.2018.1433099

Published online: 18 Apr 2018.

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Mental Health Among Incarcerated Women: An Examination of Factors Impacting Depression

and PTSD Symptomology

Mollimichelle Cabeldue Department of Psychology, Fairleigh Dickinson University, Teaneck, NJ, USA

Ashley Blackburn Department of Criminal Justice and Social Work, University of Houston Downtown,

Houston, TX, USA

Janet L. Mullings College of Criminal Justice, Sam Houston State University, Huntsville, TX, USA

Female offenders experience mental health symptoms at a higher rate than male offenders and females in the community. The current study investigated individual characteristics and experiences that may impact symptoms of depressive disorders and posttraumatic stress disorder (PTSD) among a sample of female inmates in a large Southern prison system. Results showed high rates of reported childhood and adult victimization experiences among the sample. Factors such as seeking mental health treatment prior to incarceration significantly impacted the reporting of depressive and PTSD symptoms, as did victimization histories. Findings suggest that women would benefit from screen- ing to identify mental health needs at the onset of incarceration as well as gender responsive needs assessment and programming to address histories of victimization and current mental health symptomatology.

Keywords depression, female offenders, mental health, PTSD, victimization

INTRODUCTION

As the rate of incarcerated females has increased over the past two decades, there has been a renewed interest in topics pertaining to female offenders (Carson & Golinelli, 2013; DeHart, 2008; Rose, LeBel, & Blakey, 2016). One important factor facing state female inmates is a high rate of mental illness (Harner & Riley, 2013; Wolff et al. 2010; Wright et al., 2012). In a national survey of inmates, James and Glaze (2006) found that state prison inmates were more likely than jail or federal prison inmates to have mental health issues, with more than 705,000 state inmates reporting a mental health problem in 2005. Female inmates in state prisons had

none defined

Correspondence should be sent to Ashley G. Blackburn, PhD, Department of Criminal Justice & Social Work, One Main Street C-340 Commerce Building Houston, TX 77002-1001, USA. E-mail: [email protected]

DOI: 10.1080/08974454.2018.1433099

Women & Criminal Justice, 29: 52–72, 2019 Copyright © Taylor & Francis Group, LLC ISSN: 0897-4454 print/1541-0323 online

higher rates of mental health problems when compared to their male counterparts, 73%�versus 55%, respectively. More recently, Bronson and Berzofsky (2017) found that nearly 8%�more female than male prisoners reported serious psychological distress when responding to a 2011–2012 Bureau of Justice Statistics survey.

A better understanding of current female inmate characteristics and their relationship to mental health may highlight the importance of intervention within women’s prisons. Addition- ally, it may add to our understanding of the pathway of mental health development, especially among female inmates. Although a fair amount of research addresses the topic of mental health disorders among female offenders, much of this research is either outdated, conducted with offenders outside the United States, or focuses on federal inmates or jail detainees (e.g., Derkzen, Booth, Taylor, & McConnell, 2013; Diamond, Magaletta, Harzke, & Baxter, 2008; Green, Miranda, Daroowalla, & Siddique, 2005; Watzke, Ullrich, & Marneros, 2006). The current study seeks to update findings regarding mental health and related factors such as victimization histories and prior mental health treatment, utilizing a sample of female inmates from a large Southern prison system.

LITERATURE REVIEW

Mental Health Prevalence and Presentation

Although research is limited in what we know specifically about mental health diagnoses for women in state prisons, findings have shown that incarcerated women who are serving short sentences have significantly more mental health problems when compared to incarcerated men (Abram, Teplin, & McClelland, 2003; James & Glaze, 2006; Steadman, Osher, Robbins, Case, & Samuels, 2009). In comparison to male inmates, female inmates have higher rates of major mental illness including schizophrenia, posttraumatic stress disorder (PTSD), depress- ive disorders, certain personality disorders (e.g., borderline personality disorder) and substance abuse problems (Blanchette & Brown, 2006). Mental health issues also affect female offenders differently. For example, female offenders often have different symptoms than their male offender counterparts (Covington, 2003a; Drapalski, Youman, Stuewig, & Tangney, 2009) and show an increased vulnerability to certain stressors associated with incarceration such as being away from children (Covington, 2003a). Female inmates also show more significant histories of mental illness. James and Glaze (2006) found that 25%� of incarcerated women reported a diagnosable mental health disorder in the year preceding their incarceration, whereas only 8%�of men made a similar report.

Female inmates also have higher rates of mental health problems when compared with women in the community (Blanchette & Brown, 2006; Bloom, Owen, & Covington, 2003). For example, PTSD has been found to be between four and 10 times more prevalent among female offenders when compared to samples of females in the community (Green, Miranda, Daroowalla, & Siddique, 2005; Trestman, Ford, Zhang, & Wiesbrock, 2007). Although female offenders show high rates of almost all mental disorders, they show disproportionately high rates of affective disorders such as depression and trauma disorders such as PTSD (Bloom, Owen, & Covington, 2004). As such, these two diagnoses were the focus of the current study.

MENTAL HEALTH AMONG INCARCERATED WOMEN 53

PTSD

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), PTSD is characterized by the development of symptoms such as avoidance, intrusion, negative alterations in cognitions and mood, and alterations in arousal and reactivity as a result of a traumatic event, which may include threat of death, serious injury or sexual violence (American Psychiatric Association [APA], 2013). PTSD has a heterogeneous presentation and can present with a variety of behaviors such as nightmares, loss of interest in activities, or an exaggerated startle response among others. In regard to PTSD presentation in offenders, Grella, Lovinger, and Warda (2013) found that the exposure to previous trauma was associated with an increase in the rate of PTSD in a female offender sample. Additionally, Wolff et al. (2010) found high rates of PTSD in female offenders as a result of extensive victimization histories; nearly 93%�reported symptoms of PTSD. In regard to the utilization of mental health services, female inmates with severe PTSD symptoms were more likely to report using prison mental health services when compared to women who had mild to no PTSD symptomology (Harner et al., 2013). Women with severe PTSD symptomology were more likely to suffer from other mental health conditions as well and were more likely to be taking medication for depression, anxiety and sleep problems.

Depression

According to the DSM-5, major depressive disorder is characterized by a combination of depressed mood, anhedonia (i.e., the inability to experience pleasure from activities one used to enjoy), disorganized sleep, fatigue, irritability, psychomotor agitation or retardation, feelings of worthlessness, decreased ability to concentrate, and suicidal thoughts or actions (APA, 2013). Like PTSD, it also has a heterogeneous presentation and affects individuals differently.

Depression has been found to be one of the most prevalent mental health diagnoses for female inmates (James & Glaze, 2006) and researchers have found that depression diagnoses are on the rise among offenders in the United States (Fazel & Seewald, 2012). James and Glaze (2006) found that nearly 24%�of state female inmates in their sample reported five or more symptoms of major depressive disorder. Most commonly, females reported symptoms of disturbed sleep and persistent anger. Relatedly, research has indicated high rates of suicide and past suicide attempts among female offenders. Suicide has been noted as the second leading cause of death in U.S. prisons (Mumola, 2005). Consistent with general mental health preva- lence, suicide rates are consistently higher for female offenders than for male offenders or for female community members (Tartaro & Ruddell, 2006). Dye and Aday (2013) investigated the prevalence of suicidal ideation and suicide attempts in women serving life sentences and found that 45%� reported thoughts of suicide before they were incarcerated. Importantly, depression was found to be a significant predictor of suicidal ideation.

Factors That Influence/Impact Mental Health

Previous research has shown that depressive and PTSD symptomology are prevalent among female state prison samples. Researchers have examined the reasons for increased mental health

54 M. CABELDUE ET AL.

concerns among female offenders (Bloom et al., 2003; Messina & Grella, 2006), with some investigating factors related to mental health development and exacerbation. Understanding these factors may help to draw parallels to development of mental health issues in female offender samples.

Prior Mental Health Treatment

One factor that may predict presence of mental health symptoms among female offenders is having had prior mental health treatment before incarceration. Having a history of mental health issues would assist in explaining the presence of current symptomatology given that many disorders, including depression, are episodic in nature (Solomon et al., 1997). According to James and Glaze (2006), 62%� of female inmates in their sample experienced prior mental health symptoms and 48%�had a “recent history” of mental problems. Specifically, 23%�had been formally diagnosed with a disorder by a mental health professional, 39%� had used prescription medications, and 32%�had received therapy in the year prior to their incarceration. These rates are at least twice as high when compared to rates among male offenders and consistently higher for state offenders than for offenders in local jails (James & Glaze, 2006). More recent research has found similar prevalence rates. A 2011–2012 survey suggested that 36.9%�of male and female prisoners had been diagnosed with a disorder by a mental health professional (Bronson & Berzofsky, 2017). Relevant to the current study, Bronson and Berzofsky (2017) found that 24.2%�of their sample had been diagnosed with major depressive disorder and 12.5%�had been diagnosed with PTSD (Bronson & Berzofsky, 2017). More female prisoners met the threshold for serious psychological distress (20.5%) compared to male prisoners (14.0%) and more female prisoners (65.8%) had a history of mental health problems when compared to male prisoners (34.8%).

Diamond, Magaletta, Harzke, and Baxter (2008) investigated factors that might predict federal inmates seeking psychological services at the time of admission. They found that one major predictor was receiving mental health treatment prior to their current incarceration. Harner and Riley (2013) found a majority of women inmates in their sample felt their mental health had worsened during the time they were incarcerated due to a number of factors includ- ing fear, stress, being away from home, and poor treatment from staff. This suggests that although incarceration amplified mental health concerns, many women in this sample reported entering prison with existing mental health issues.

Histories of Abuse/Victimization

One factor that prior research has consistently linked to mental health issues among offender populations is presence of abuse or victimization histories. Existing research shows that female offenders enter prison with significant victimization histories, including episodes of child abuse, domestic abuse, and sexual assault, among other types (Grella, Lovinger, & Warda, 2013; Harner, Budescu, Gilihan, Riley, & Foa, 2013; Wolff et al., 2010). Although male offenders suffer from victimization as well, this issue has been found to be considerably more prevalent among female offenders (James & Glaze, 2006). Furthermore, female offenders appear to suffer from higher rates of victimization compared to women in general society. For example, Grella,

MENTAL HEALTH AMONG INCARCERATED WOMEN 55

Lovinger, and Warda (2013) found that their incarcerated sample had a significantly higher rate of trauma exposure including serious accidents, sexual trauma, and disasters when compared to women in the community.

Findings overwhelmingly demonstrate that high rates of female offenders have experienced victimization during their lifetime. Wolff et al. (2010) found that 93%� of inmates in their sample reported a history of traumatic events in their lifetime. Specifically, 71%�reported child- hood violence and more than 80%�reported adult violence. Harner et al. (2013) found similar results with more than 50%�of their sample reporting traumatic experiences. Clements-Nolle, Wolden, and Bargmann-Losche (2009) also found high rates of prior victimization among their female inmate sample; 58%� reported emotional abuse, 54%� reported physical abuse, 51%�

reported sexual abuse, 53%� reported emotional neglect, and 41%� reported physical neglect. Byrd and Davis (2009) reported even higher exposure rates among their sample of female offen- ders, finding that 85%� reported some sort of trauma history. Moreover, 65%� reported both childhood and adult trauma, indicating that female inmates who experience trauma are likely to experience it throughout multiple developmental periods.

Research suggests that high rates of victimization are significant contributing factors to mental health concerns among women specifically. Victimization has been found to be related to higher rates of PTSD, depression, and anxiety-related disorders among female inmates who have higher rates of victimization when compared with male inmates (Henderson, Schaeffer, & Brown, 1998; Veysey, 1998). Victimization histories appear related to specific mental health concerns as well. For example, a history of previous abuse is associated with psychiatric symp- toms such as suicide attempts (Clements-Nolle, Wolden, & Bargmann-Losche, 2009; Dye & Aday, 2013). Chapman, Specht, and Cellucci (2005) investigated prevalence of past suicide attempts among female offenders and found that 38%� of female offenders reported a past suicide attempt. In their sample, suicide attempts were related to the presence of a personality disorder, hopelessness, depression, childhood abuse, family history of suicide, and mood disorders.

Researchers have also begun to focus on the presence multi-victimization histories. Kennedy, Tripodi, Pettus-Davis, and Ayers (2016) examined the relationship between childhood victimi- zation and mental health symptoms including depression, psychosis, and substance misuse using a dose–response curve in a sample of 230 female offenders. They found that both fre- quency of physical abuse and sexual abuse predicted symptoms of psychosis, and frequency of physical abuse predicted substance misuse. Their findings also suggested that multiple incidents of victimization increased a female offender’s risk for experiencing mental health symptoms. Specifically, female offenders with multiple incidents of victimization were 5.7 times more likely to report symptoms of depression, 4.2 times more likely to report symptoms of psychosis, and 3.8 times more likely to meet criteria for a substance use disorder.

Other research supports the finding that multiple incidents of victimization increase the likelihood that a woman will experience mental health problems. In fact, prior research suggests that the number of victimizations a person experiences more accurately predicts distress than any single form of victimization (Finkelhor, Ormrod, Turner, & Hamby, 2005). Examining the impact of sexual abuse on physical and mental health of female offenders, Aday, Dye, and Kaiser (2014) found that those with histories of abuse were more likely to report health problems and more mental health diagnoses and increased symptoms of mental health issues including paranoia and symptoms of depression. More importantly, those offenders with

56 M. CABELDUE ET AL.

multiple incidents of abuse were likely to suffer from higher levels of these same symptoms as well as increased risk for suicide.

Parental Status

According to Bloom and Covington (2009), the most stressful part of female incarceration is separation from children. In a female inmate sample studied by Rodda and Beichner (2017), of whom 44%�had children under the age of 18, the women discussed concern for their children and many described feelings of loneliness they experience as a result of being separated from their children. These women reported feeling as if their relationship with their children was suffering and discussed the difficultly of visiting with children while in prison. Harner and Riley (2013) conducted focus groups among female inmates and found themes included feelings of guilt about not being a good mother, being separated from children and family, worrying about a child’s health and safety, and difficulty in arranging visits due to financial constraints and long commutes (Harner & Riley, 2013). Women in this study also cited parenting concerns and separation from family as a reason for worsening mental health during incarceration.

Other Related Demographic Factors

Statistics on mental health among incarcerated populations suggest that some demographic fac- tors such as age and education level may differentiate between offenders with mental health prob- lems and those without (James & Glaze, 2006). For example, prevalence of mental health problems appears to vary by age with younger inmates having higher rates of mental health problems (James & Glaze, 2006). Among state prison inmates, James and Glaze (2006) found that an estimated 63%�

of inmates age 24 or younger had mental health problems. Research by Bronson and Berzofsky (2017) confirmed this, finding that prisoners above 65 years old in their sample were less likely than prisoners between the ages of 18 and 24 years old to report severe psychological distress. In addition, Bronson and Berzofsky (2017) found that more offenders without high school diplomas reported severe psychological distress when compared to offenders who had graduated high school or obtained a college degree. In contrast, however, 41%�of offenders with college degrees had pre- viously been diagnosed with a mental disorder, whereas only 38%�of those who did not complete high school had previously been diagnosed (Bronson & Berzofsky, 2017).

Negative Consequences and Treatment Needs

The need for understanding characteristics and experiences that relate to female offender mental health development has important implications. Consequences for mental health symptoms are significant. Female offenders, especially those who have histories of victimization, often suffer exten- sive negative outcomes. One issue is that women with a history of victimization have been found to go on to demonstrate violent behavior themselves (Batchelor, 2005; Byrd & Davis, 2009; Pollock, Mullings & Crouch, 2006). Wolff et al. (2010) found that women with severe PTSD symptoms were more likely to be incarcerated for a violent crime when compared to women with sub-threshold PTSD.

Victimization and mental health issues also appear to play a role in institutional violence (Martin, Eljdupovic, McKenzie, & Colman, 2015). In an international study examining the

MENTAL HEALTH AMONG INCARCERATED WOMEN 57

association between trauma, mental health, substance abuse, juvenile charges, and institutional violence within the first six months of incarceration, results revealed that mental health, substance abuse, and youth charges all interacted to predict violence. Additionally, there was a direct correlation between trauma and institutional aggression, with offenders having trauma histories engaging in more aggressive incidents during the first six months of their incarceration.

Given previous findings focused on negative outcomes, it is not surprising that mental health services are utilized more frequently by female offenders (James & Glaze, 2006). Female offen- ders make greater use of correctional mental health services when compared to male offenders (James & Glaze, 2006). Research has shown that demographic characteristics such as race and histories of mental health and substance abuse disorders are strong predictors of service delivery to female inmates (Faust & Magaletta, 2010; Teplin, Abram, & McClelland, 1997). Addition- ally, Diamond, Magaletta, Harzke, and Baxter (2008) found that females were more likely than male inmates to request services and female requesters were more likely to report prior mental health treatment, medication use, and overall psychological symptoms.

Although these findings have informed us about female inmates who receive correctional mental health treatment, there are still many unknowns. Most importantly, perhaps, is a contin- ued lack of understanding about the characteristics that differentiate offenders with mental illness from those without mental illness. A better understanding of this would allow for more targeted treatment and intervention that might serve female offenders during incarceration. Additionally, an understanding of the characteristics associated with mental illness in female offenders would provide an indication of what correctional facilities could screen for at the onset of incarceration. This may decrease issues later in incarceration.

THE CURRENT STUDY

The current study builds on previous research (Mullings, Hartley, & Marquart, 2004; Mullings, Marquart, & Brewer, 2000; Mullings, Marquart, & Hartley, 2003; Pollock, Mullings, & Crouch, 2006) examining the presentation of mental health issues among females incarcerated in a large Southern prison system. The interrelationships between characteristics and experiences of female offenders and their current reported mental health are examined guided by the following research questions: (a) do offender characteristics included in this study (e.g., prior mental health treatment, victimization history) impact self-reporting of depression and PTSD symp- toms among female inmates? and (b) does frequency of self-reported victimization experiences increase self-reported depression and PTSD symptoms among female inmates?

Sample and Survey Administration

The population of interest for the present study consists of women incarcerated across multiple units in a large Southern prison system. Data collection began in August 2015 and concluded in April 2016, yielding a sample of 545 usable self-report surveys from study participants. Participants included both female inmates sentenced to the institutional division/state prison (n ¼ 378) and female inmates sentenced to a state jail facility (n ¼ 167). Female inmates in the state jail subgroup were convicted of state jail felonies and are serving sentences of two years or less. Institutional division inmates are also housed at state jail facilities as these facilities are

58 M. CABELDUE ET AL.

designated as transfer units for inmates awaiting transfer to a prison unit. Participants were classified as part of the general population on each unit included in the study. Sampling varied by unit and was based on the unit’s resources available to support data collection activities.

Survey administrations were conducted during different trips to the units and were conducted by one or two members of the research team. Once in the survey administration area, all women were informed of the study, told their responses would remain anonymous, and that they could withdraw their consent at any time without penalty, and were asked for their informed consent. Most participants completed the survey within 45 minutes. Once an inmate finished the survey, she was escorted back to her normally scheduled activities either individually or as part of a group.

Instrument, Variables, and Plan of Analysis

The survey instrument included measures about institutional programming, substance abuse, mental and physical health, abuse histories, institutional safety, contact with children, plans for reentry, and demographic items. As the current study focuses on mental health among the sample, the dependent variables include scale scores measuring depression and PTSD symp- toms. Items for both scales are listed in Table 1. Both depression and PTSD symptoms were measured using emerging measures for research and clinical evaluation developed by the American Psychiatric Association (APA) to provide consistency in research (APA, 2013). Both are accessible through the public domain and available for use without permission. They are consistent with the fifth and most current edition of the DSM.

TABLE 1 Depression Scale Items and PTSD Scale Items

Scale items Depression scale items 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that

you have been moving around a lot more than usual PTSD scale items 1. Having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all

over again (e.g., you re-experienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?

2. Feeling very emotionally upset when something reminded you of a stressful experience 3. Trying to avoid thoughts, feelings, or physical sensations that reminded you of a stressful experience? 4. Thinking that a stressful event happened because you or someone else (who didn’t directly harm you) did something

wrong or didn’t do everything possible to prevent it, or because of something about you? 5. Having a very negative emotional state (e.g., you were experiencing lots of fear, anger, guilt, shame or horror) after a

stressful experience? 6. Losing interest in activities you used to enjoy before having a stressful experience? 7. Being “super alert,” on guard, or constantly on the lookout for danger? 8. Feeling jumpy or easily startled when you hear an unexpected noise? 9. Being extremely irritable or angry to the point where you yelled at other people, got into fights, or destroyed things?

MENTAL HEALTH AMONG INCARCERATED WOMEN 59

Depression was measured using the Severity Measure for Depression–Adult, which is adapted from the Patient Health Questionnaire–9. It includes nine items that assess for common symptoms of depression with higher scores indicating greater severity of depressive symptoms. Instructions for the depression items stated, “Over the last 7 days, how often have you been bothered by any of the following problems?” Response categories were 0 ¼ not at all, 1 ¼ several days, 2 ¼more than half the days, and 3 ¼ nearly every day. For the current study, Item 9 (“Thoughts that you would be better off dead or of hurting yourself in some way”) was removed from the scale at the request of prison administrators. Additionally, some research suggests that this item is a poor screening item for suicide (Razykov, Ziegelstein, Whooley, & Thombs, 2012). The removal of this item did not negatively affect reliability. Cronbach’s alpha for the depression scale used in the current study was .87.

PTSD symptoms were assessed using an emerging measure presented by the APA as well, the Severity of Posttraumatic Stress Symptoms–Adult (National Stressful Events Survey PTSD Short Scale). This scale includes nine items that assess for common symptoms of PTSD; higher scores indicate more severe symptomology. Instructions for the PTSD items stated, “People sometimes have problems after extremely stressful events or experiences. How much have you been bothered during the past seven (7) days by each of the following problems that occurred or became worse after an extremely stressful event/experience?” Response categories for the PTSD scale included 0 ¼ not at all, 1 ¼ a little bit, 2 ¼moderately, 3 ¼ quite a bit, and 4 ¼ extremely. Reliability analyses for the PTSD scale resulted in a Cronbach’s alpha of .92.

Independent variables included the following demographic items: age (metric), institution type (0 ¼ state jail; 1 ¼ institutional division), never married (0 ¼married, divorced, or widowed; 1 ¼ never married), minority race (0 ¼ not minority/Caucasian; 1 ¼minority), sexual orientation (0 ¼ nonheterosexual; 1 ¼ heterosexual), high school completion (0 ¼ not high school complete; 1 ¼ high school complete), employed prior to incarceration (0 ¼ not employed; 1 ¼ employed), parent status (0 ¼ no children; 1 ¼ children), first time prison inmate (0 ¼ no; 1 ¼ yes), violent offense (0 ¼ nonviolent; 1 ¼ violent), and whether the offender had sought mental health treatment prior to entering prison (0 ¼ no; 1 ¼ yes). Respondents were asked about their childhood and adulthood experiences with emotional, physical, and sexual abuse (0 ¼ no; 1 ¼ yes). Respondents who indicated they had been abused were asked how frequently each type of abuse occurred (0 ¼ no abuse reported; 1 ¼ once or twice during lifetime; 2 ¼ once or twice a year; 3 ¼ once or twice a month; 4 ¼ once or twice a week; 5 ¼ daily).

Following reliability and validity assessments of the depression symptom scale and the PTSD symptom scale, bivariate analyses were conducted to determine relationships between independent variables and scale scores. Following, multiple ordinary least squares (OLS) regression models were conducted separating the impact of frequency of childhood and adulthood abuse experiences on depression scale scores and PTSD scale scores.

RESULTS

Sample Characteristics

Group differences in descriptive statistics based on depression and PTSD scale scores appear in Table 2. The sample was made up of 545 female inmates, whose mean age was 38.9 years.

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All participants were literate and English speaking. It was a racially diverse sample, with 57.2%�

of women identifying as minorities. Regarding family, 61.7%�reported being married, divorced, or widowed and the majority (82.3%) of women reported having one or more children. Although 65.8%� of the sample reported completing high school, 43.8%� reported not being employed prior to incarceration. Nearly 76%�of the sample identified as heterosexual. Less than half of the sample reported seeking mental health treatment prior to prison. Additionally, most women reported being incarcerated for a nonviolent offense (65.9%) and being incarcerated for the first time (64.9%). Findings revealed high rates of prior victimization among the sample with 73.8%� reporting some form of child abuse, 80.0%� reporting adult abuse, and 87.7%�

reporting abuse during their lifetime. Frequency of these abuse experiences varied. Of the respondents reporting childhood

emotional abuse, 47.7%� reported daily emotional abuse, 28.2%� reported weekly emotional

TABLE 2 Group Differences in Depression and PTSD Mean Scale Scores

Variable

Depression scale score PTSD scale score

M SD M SD

Institution type Institutional Division (n ¼ 378) 11.45 6.74 14.38** 10.33 State Jail (n ¼ 167) 12.43 6.48 16.97 10.65

Minority Nonminority (n ¼ 233) 11.74 6.55 14.65 10.06 Minority (n ¼ 312) 11.76 6.77 15.56 10.79

Marital status Married, divorced, or widowed (n ¼ 336) 12.33 6.61 14.16 10.54 Never married (n ¼ 209) 11.39 6.69 16.79* 10.22

Parent Status No children (n ¼ 96) 12.18 6.44 15.55 9.62 Have one or more children (n ¼ 449) 11.66 6.72 15.09 10.67

High school graduate Not high school complete (n ¼ 186) 11.96 6.66 15.42 10.79 High school complete (n ¼ 359) 11.64 6.69 15.04 10.34

Employed prior to prison Not employed (n ¼ 239) 12.58* 6.21 15.93 10.32 Employed (n ¼ 306) 11.11 6.95 14.58 10.59

Sexual orientation Not heterosexual (n ¼ 132) 12.32 6.29 17.74** 9.99 Heterosexual (n ¼ 413) 11.57 6.78 14.35 10.52

First-time inmate No (n ¼ 191) 11.65 6.74 14.77* 10.41 Yes (n ¼ 354) 11.81 6.64 15.39 10.54

Violent offense Nonviolent offense (n ¼ 358) 12.38** 6.55 15.62 10.53 Violent offense (n ¼ 187) 10.55 6.75 14.31 10.38

Treated for mental health issues prior to incarceration No (n ¼ 316) 10.06*** 6.36 12.49** 9.94 Yes (n ¼ 229) 14.08 6.40 18.87 10.10

Note. *p < .05, **p < .01, ***p < .001.

MENTAL HEALTH AMONG INCARCERATED WOMEN 61

abuse, and 13.5%�reported monthly emotional abuse. Of the respondents reporting childhood physical abuse, 24.9%� reported daily physical abuse, 26.9%� report weekly physical abuse, and 26.0%� reported monthly physical abuse. Of the respondents reporting childhood sexual abuse, 14.5%� reported daily sexual abuse, 23.8%� reported weekly sexual abuse, and 17.8%�

reported monthly sexual abuse. Experiences with adult abuse also varied among the sample. Of the respondents reporting

adult emotional abuse, 42.5%� reported daily emotional abuse, 25.2%� reported weekly emotional abuse, and 17.5%�reported monthly emotional abuse. Of the respondents reporting adult physical abuse, 22.7%� reported daily physical abuse, 31.7%� reported weekly physical abuse, and 22.1%� reported monthly physical abuse. Finally, of those respondents reporting adult sexual abuse, the majority (63.9%) reported that this occurred once or twice during their adulthood (18.6%) or once or twice a year (45.3%).

Bivariate analyses were conducted to determine how demographic variables correlated with scale scores. There was not a significant difference between institutional division and state jail offenders regarding their depression scale scores. Inmates not employed prior to prison, offen- ders convicted of nonviolent offenses, and offenders who had sought mental health treatment prior to prison had significantly higher depression scale scores compared to other inmates. Female inmates reporting childhood emotional, physical, and sexual abuse had significantly higher depression scale scores than inmates with no history of these respective childhood abuse categories. Similarly, inmates reporting adult emotional, physical, and sexual abuse had signifi- cantly higher depression scale scores than inmates with no history of adult abuse.

Bivariate analyses were also conducted to determine how independent variables correlated with PTSD scale scores. State jail inmates and younger inmates were significantly more likely to have higher PTSD scale scores. Inmates who had never been married, inmates who were treated for mental health issues on the outside, inmates who were not heterosexual, and first time inmates had significantly higher PTSD scale scores. Additionally, inmates with abuse histories had significantly higher PTSD scale scores. Inmates reporting childhood emotional, physical, and sexual abuse had significantly higher PTSD scale scores than offenders not reporting those individual types of abuse. Similarly, inmates reporting adult emotional, physical, and sexual abuse had significantly higher PTSD scale scores.

OLS Regression Models

The last phase of analysis consisted of separate OLS regression models for the frequency of each abuse type to determine how well the independent variables in this study predicted female offender depression scale scores and PTSD scale scores, controlling for whether the inmate was sentenced to the institutional division or state jail. Six OLS regression models were conducted per scale, three examining the influence of childhood victimization histories (see Table 3) and another three examining the influence of adult victimization histories (see Table 4).

Consistent for all of the models predicting depression scale scores, female inmates who had sought mental health treatment prior to entering prison and female inmates incarcerated for a nonviolent offense were significantly more likely to have higher scores on the depression scale. Additionally, abuse type frequency was significantly predictive of higher scores on the depression scale across all of the models. One unique finding was that female inmates who were

62 M. CABELDUE ET AL.

not employed prior to incarceration were significantly more likely to have higher scores on the depression scale in the adult emotional abuse model (Table 4, Model 1). Model R2 statistics for the models examining depression scale scores ranged from 12.4%� to 14.3%.

Tables 5 and 6 present the results of OLS regression models for which PTSD scale score was the dependent variable. Again, female inmates who had sought mental health treatment outside

TABLE 3 OLS Regression Models for Depression Scale Scores by Frequency of Childhood Abuse Types

Variables

Model 1 Model 2 Model 3

B Beta B Beta B Beta

Institution type .349 .024 .345 .024 .264 .018 Minority .190 .014 −.020 −.002 −.121 −.009 Never married 1.019 .074 1.060 .077 1.013 .074 MH treatment outside 3.356*** .249 3.556*** .264 3.578*** .266 Violent offense −2.024** −.144 −1.984** −.141 −1.959** −.140 Employed −1.064 −.079 −1.057 −.079 −1.027 −.076 Age −.016 −.026 −.022 −.035 −.024 −.038 High school graduate −.179 −.013 −.105 −.007 −.143 −.010 Heterosexual −.067 −.004 .021 .001 −.063 −.004 First-time inmate .969 −.69 .954 .068 1.006 .072 Parent −.447 −.026 −.526 −.030 −.507 −.029 Freq child emotional abuse .407** .134 — — — — Freq child physical abuse — — .408** .120 — — Freq child sexual abuse — — — — .341* .089 R2 13.2*** 13.0%*** 12.4%***

Note. *p < .05, **p < .01, ***p < .001.

TABLE 4 OLS Regression Models for Depression Scale Scores by Frequency of Adult Abuse Type

Variables

Model 1 Model 2 Model 3

B Beta B Beta B Beta

Institution type .356 .025 .234 .016 .182 .013 Minority .209 .016 .027 .002 −.049 −.004 Never married 1.165 .085 1.090 .080 1.057 .077 MH treatment outside 3.364*** .250 3.445*** .256 3.614*** .269 Violent offense −2.089** −.149 −1.955** −.139 −1.969** −.140 Employed −1.110* −.083 −1.040 −.077 −1.090 −.081 Age −.011 −.018 −.016 −.026 −.023 −.036 High school graduate −.401 −.029 −.056 −.004 −.123 −.009 Heterosexual −.315 −.020 −.209 −.013 −.121 −.008 First-time inmate 1.049 .075 1.132 .081 .937 .067 Parent −.549 −.031 −.611 −.035 −.574 −.033 Freq adult emotional abuse .541*** .170 — — — — Freq adult physical abuse — — .578*** .166 — — Freq adult sexual abuse — — — — .464* .101 R2 14.3%*** 14.3%*** 12.6%***

Note. *p < .05, **p < .01, ***p < .001.

MENTAL HEALTH AMONG INCARCERATED WOMEN 63

of prison were consistently significantly more likely to have higher PTSD scale scores across all six models. Being single at the time of incarceration was a significant predictor in each of the models as was abuse history. Identifying as nonheterosexual was a significant predictor of higher PTSD scales scores in each of the six models except the childhood physical abuse model.

TABLE 5 OLS Regression Models for PTSD Scale Scores by Frequency of Childhood Abuse Types

Variables

Model 1 Model 2 Model 3

B Beta B Beta B Beta

Institution type −1.541 −.068 −1.512 −.067 −1.722 −.076 Minority 1.05 .050 .665 .031 .391 .018 Never married 2.395* .111 2.493* .116 2.381* .111 MH treatment outside 6.262*** .296 6.618*** .313 6.736*** .318 Violent offense −7.85 −.036 −.722 −.033 −.647 −.029 Employed −.489 −.023 −.453 −.021 −.410 −.019 Age −.033 −.034 −.046 −.046 −.049 −.049 High school graduate .321 .015 .499 .023 .398 .018 Heterosexual −2.181* −.089 −1.900 −.078 −2.171* −.089 First-time inmate 1.333 .061 1.304 .059 1.414 .064 Parent .959 .035 .748 .027 .829 .030 Freq child emotional abuse .875*** .183 .189 Freq child physical abuse — — 1.011*** Freq child sexual abuse — — .738** .123 R2 19.2%*** 19.6*** 17.6%***

Note. *p < .05, **p < .01, ***p < .001.

TABLE 6 OLS Regression Models for PTSD Scale Scores by Frequency of Adult Abuse Types

Variables

Model 1 Model 2 Model 3

B Beta B Beta B Beta

Institution type −1.515 −.067 −1.788 −.079 −1.931 −.085 Minority 1.136 .054 .690 .033 .631 .030 Never married 2.721** .126 2.543* .118 2.493* .116 MH treatment outside 6.242*** .295 6.480*** .306 6.721*** .318 Violent offense −.941 −.043 −.635 −.029 −.700 −.032 Employed −.587 −.028 −.444 −.021 −.527 −.025 Age −.022 −.022 −.033 −.034 −.047 −.048 High school graduate −.177 −.008 .577 .026 .463 .021 Heterosexual −2.720** −.111 −2.493* −.102 −2.217* −.091 First-time inmate 1.514 .069 1.667 .076 1.261 .057 Parent .727 .026 .624 .023 .585 .021 Freq adult emotional abuse 1.211*** .242 — — — — Freq adult physical abuse — — 1.195*** .218 — — Freq adult sexual abuse — — — — 1.263*** .174 R2 21.5%*** 20.7%*** 19.1%***

Note. *p < .05, **p < .01, ***p < .001.

64 M. CABELDUE ET AL.

Model R2 statistics ranged between 17.6%�and 21.5%, indicating better model fit for PTSD scale scores as compared to prediction of variance among depression scale scores.

DISCUSSION

By examining mental health issues and other experiences among female inmates, the current study sought to add to previous research in this area using a recent sample of female inmates. Specifically, we investigated whether characteristics and experiences of female offenders were related to current mental health symptoms of depression and PTSD. The findings presented above offer a better understanding of current prevalence and presentation of victimization history and its relationship to mental health issues among female state prisoners. They also offer a better understanding of demographic factors that relate to mental health presentation.

Results showed high rates of victimization across the lifetime in the current sample. Overall, women reported high rates of emotional, physical, and sexual abuse as both children and adults. Although the frequency of abuse varied, women reported various forms of abuse occurring as often as daily throughout their lifetime. The high rates of victimization found in this study are consistent with those in previous research among female offender samples (e.g., Grella, Lovinger, & Warda, 2013; Harner et al., 2013; Wolff et al., 2010). Additionally, the rates in the current sample actually exceed those found in some samples (e.g., Clements-Nolle, Wolden, & Bargmann-Losche, 2009).

These findings are also consistent with previous research linking victimization experiences and poor mental health (e.g., Aday, Dye, & Kaiser, 2014; Clements-Nolle, Wolden, & Bargmann-Losche, 2009; Grella, Lovinger, & Warda, 2013; Kennedy et al., 2016; Wolff et al., 2010). The current results demonstrated that offenders who reported childhood and adult experiences of physical, sexual, and emotional victimization all had significantly higher depression and PTSD scale scores when compared to offenders without these types of victimiza- tion experiences. These are critical findings for correctional authorities as they suggest a vast majority of female offenders are entering prison with extensive, and varied, victimization experi- ences that may be contributing to increased mental health issues such as depressive and PTSD symptoms. This finding is particularly important for correctional settings to attend to as prior research suggests that mental health symptoms can lead to negative consequences both in prison and after release. Mental health symptoms can impact behavior while in prison (Adams & Ferrandino, 2008). Symptoms of depression and anxiety may make it difficult for offenders to follow institutional rules (Adams & Ferrandino, 2008). One study found that prison inmates with diagnosed mental illnesses were more likely to serve longer sentences when compared with inmates without mental health diagnoses (Ditton, 1999), which may have long-term economic consequences for correctional facilities. Research has also shown that individuals with trauma history may be more likely to commit institutional aggression during the first few months of incarceration for various reasons (Martin, Eljdupovic, McKenzie, & Colman, 2015).

The current study highlighted a number of demographic variables that were related to higher self-reported symptoms of depression and PTSD, extending prior research. One important find- ing was that female inmates who had been treated for mental health issues prior to incarceration were found to have significantly higher PTSD and depression scores. This finding supports pre- vious research by Diamond, Magaletta, Harzke, and Baxter (2008), who found that prior mental

MENTAL HEALTH AMONG INCARCERATED WOMEN 65

health treatment was a predictor of which federal inmates would seek psychological services at the time of prison admission. It is likely that women who have obtained psychological services in the community may continue to experience or re-experience symptoms during their incarcer- ation, especially with the increased rates of stress associated with incarceration. These findings may indicate the need for use of a screening tool, which would identify inmates who might benefit from services at the onset of incarceration, which would improve continuity of care.

Additionally, women who were not employed prior to prison and those convicted of nonviolent offenses were more likely to have higher depression scale scores. State jail inmates, younger inmates, and inmates who had never been married had higher PTSD scale scores than their counterparts. Although not all women falling into these categories can be prioritized for treatment during incarceration, these findings offer suggestions as to who might be more likely to experience symptoms during incarceration. These findings offer suggestions for future research interventions to target mental health symptoms in incarcerated females as well. For example, targeting future employability and social support may be critical areas of focus in treatment of those with depressive and PTSD symptoms.

Findings from the current study also demonstrated that victimization frequency both as a child and as an adult was a significant predictor of higher depression and PTSD scale scores in combination with other variables. In predicting depression, abuse frequency as a child and an adult was predictive in all models (emotional abuse, physical abuse, and sexual abuse) along with prior mental health treatment, and committing a nonviolent offense. Not being employed prior to incarceration also contributed to the adult models, but not the childhood models. In predicting PTSD, abuse frequency as a child and an adult was predictive in all models along with prior mental health treatment, being single, and identifying as not-heterosexual (except for in the childhood physical abuse model). These findings aid our understanding of the role that frequency of abuse plays in mental health symptomology. Although many studies have investigated prevalence and/or impact of different types of abuse (e.g., Clements-Nolle, Wolden, & Bargmann-Losche, 2009; Dye & Aday, 2013; Harner et al., 2013) and some others have looked at experience of traumatic events over different developmental periods (e.g., Byrd & Davis, 2009; Wolff et al., 2010), fewer studies focus on frequency of abuse. This appears to be an emerging area of research though and our results are consistent with the few studies focusing on frequency of victimization. Kennedy et al. (2016) found similar findings in their investigation of frequency of childhood victimization on mental health symptoms. These researchers found that women who experienced multiple acts of victimization as children were more likely to report symptoms of depression, psychosis, and substance use disorders. Our current findings echo their findings regarding childhood victimization for the symptoms we investigated; female offenders with higher frequencies of victimization reported increased symptoms of depression and PTSD in our sample. Our findings extend this research by also considering frequency of adult abuse, which was also significant in contributing to increased symptoms of PTSD and depression. This extension of the literature on the relationship between victimization and mental health highlights the critical need to identify and understand female offender’s victimization experiences. Those individuals who have experienced more frequent abuse across domains and developmental periods are at an increased risk for psychological distress and thus should be prioritized for treatment. Specifically, the number of victimizations a person experiences has more accurately predicted distress more than any single form of victimization in the past (Finkelhor, Ormrod, Turner, & Hamby, 2005). In addition to previous

66 M. CABELDUE ET AL.

victimization, our findings suggest other factors that may contribute to increased symptoms including prior mental health treatment, nonviolent offenses, lack of employment prior to incarceration, and identifying as nonheterosexual. Many of these variables have been linked to stress (e.g., lack of employment with financial stress), which may explain their relationship to depressive and PTSD symptoms.

Overall, these findings suggest a need to better evaluate individual mental health upon admission. This study identified a number of demographic and historical factors related to abuse and psychological distress that could be easily assessed or monitored throughout incarceration. Additionally, they highlight the importance of identifying frequency of abuse for female offenders. It is likely that a proactive approach to addressing mental health needs of female offenders would aid in improving both the addressing of female inmate needs and issues faced by correctional administrators.

Implications for Policy and Practice

These findings have important implications for both policy and practice. They highlight the serious need for gender-responsive needs assessment and treatment in female correctional facilities, especially given prior research demonstrating the increased mental health concerns in female inmate samples. There has been a push for gender-responsive policy and practice for offenders within the last 10–15 years (Bloom, Owen, & Covington, 2004; Wright et al., 2012); however, the lack of research on female prison programming and policies has left unknown whether successful implementation of such programs has occurred. Our data suggest that female inmates are still suffering from these concerns at significant rates that match or exceed those in previous samples.

Regarding policy, correctional facilities may need to alter or improve the screening assess- ments that take place at admission to include identifying women with a history of victimization histories at the onset of incarceration. According to Matheson, Brazil, Doherty, and Forrester (2015), many prison systems screen for factors that relate to risk factors for criminality so that these factors can be targeted during incarceration. As trauma is not often included as a risk factor, it is often neglected in the screening process. Prison systems should prioritize the assessment of victimization history for effective treatment during incarceration.

Gender responsive policies often focus on rehabilitation and treatment for female offenders, which is critical in addressing mental health concerns. Programming to address the vast experiences of victimization experienced by female inmates are critical. Specifically, prison programming should focus on consequences of victimization (McDaniels-Wilson & Belknap, 2008) and help women recognize abuse and trauma so that they can work to avoid it in future relationships (Bloom & Covington, 2009). The current study suggests that this is particularly important for female offenders who report both victimization experiences across the lifetime and for those who report various types of victimization.

Female offenders also need treatment programs that help them address past victimization (Covington, 2003b). Importantly, recent research has demonstrated that female offenders want this type of treatment. In a qualitative study focused on female inmate needs, Matheson et al. (2015) reported that one major theme that emerged throughout interviews was female offenders’ desire for help dealing with past traumas. Facilities also need programming that addresses the

MENTAL HEALTH AMONG INCARCERATED WOMEN 67

wide range of mental health issues that plague female offenders including depressive sympto- mology (Wright et al., 2012). This is especially relevant given that suicide, a common symptom of depression, has been found to be the second leading cause of death in U.S. prisons (Mumola, 2005) and that rates of suicide are higher for female inmates. Addressing concerns of depression earlier in incarceration may aid against this.

Given the high rates of victimization found among the current sample and its association with mental health symptoms, it is important that correctional authorities assess for these symptoms so that women can be identified to receive adequate treatment. Such assessment should be done when women are first incarcerated and on an ongoing basis. Given that the female inmates in the current study were assessed at different time points in their sentence and were asked to rate their symptoms for the past seven days, it suggests that they would benefit from ongoing treatment throughout incarceration.

Finally, many prison programs focus on reintegration and thus are only available shortly before a sentence expires; however, our findings suggest that women need programming throughout their incarceration. Issues related to reentry, including how to avoid abusive relationships, how to cope with prior traumas, and how to handle mental health issues should be considered throughout the duration of their sentence so they have time to implement skills and process trauma prior to reintegration (Wright et al., 2012).

Suggestions for Future Research

The results of the present study indicate the need for continued research in this area. For example, this research suggests that female offenders are experiencing high rates of depressive and PTSD symptoms. However, there is little research about the prevalence of mental health programming for female offenders or how useful it may be in treating these concerns. Future research may also identify components of treatment that are particularly useful in treating depressive and PTSD symptoms in incarcerated samples.

Additionally, although we know that there is a relationship between victimization and greater scale scores of depression and PTSD in the current study, there is limited research on the indi- vidual symptoms women experience and how those may be related to prior experiences. Future research might identify these symptoms and investigate which symptoms are most amenable to treatment so they can be addressed and emphasized in treatment.

Last, future research should further examine how demographic and related variables impact institutional mental health as well as examine differences between inmate populations. Although institution type was not significant in the multivariate model, state jail inmates had significantly higher PTSD scale scores, suggesting there may be some significant differences between the two groups. Further research confirming differences between the two groups may imply that different forms of intervention are needed for each group.

STUDY LIMITATIONS

These data are cross-sectional. For this study, a sample of female offenders was assessed at one point in time in a prison system in one part of the country. The experiences of these female offenders may differ from those of other female offenders in different locations or assessed

68 M. CABELDUE ET AL.

at a different time period. Therefore, these findings cannot be generalized to other inmate populations. Additionally, causal statements concerning the research findings cannot be made. Although the data illustrated a number of relationships between study variables, it is unknown which variables precede others in time. This is especially true for the relationship between victimization experiences and measures of mental health. Additionally, sampling may have impac- ted this study. Participation in the study was, in part, a reflection of unit resources available to assist with data collection; therefore, the decision to participate may have varied by unit.

The self-report nature of these data also presents limitations; no efforts were made to corroborate information provided by the study participants. Self-report data face a number of possible issues including inaccurate reporting. Given that the study was self-report in nature, it is unknown how individual participants conceptualized certain concepts (e.g., what constitutes emotional abuse) or whether telescoping impacted findings. Other limitations presented by self-report data include untruthfulness and social desirability. Participants may have been untruth- ful in their answers leading to over- or under-estimation of occurrence. Finally, given the sensitive nature of some of the questions, the issue of social desirability, whereby answers thought to be expected were given rather than the truthful answers, may affect the findings. Although these lim- itations exist, the results of this study are important as they focus on a recent sample of state female inmates and thus further contribute to increased understanding about incarcerated female offenders and their current experiences with victimization and mental health issues.

ACKNOWLEDGMENTS

The research described in this document was coordinated in part by the Texas Department of Criminal Justice (Research Agreement #716-AR14). The contents of this document reflect the views of the author(s) and do not necessarily reflect the views or policies of the Texas Department of Criminal Justice.

FUNDING

Data collection for this research was supported in part by a University of Houston Downtown Organized Research and Creative Activities grant awarded in December 2015 and PI Research Funds from Sam Houston State University.

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